Geographic disparities and temporal changes of diabetes prevalence and diabetes self-management education program participation in Florida

Abstract

Background Although Diabetes Self-Management Education (DSME) programs are recommended to help reduce the burden of diabetes and diabetes-related complications, Florida is one of the states with the lowest DSME participation rates. Moreover, there is evidence of geographic disparities of not only DSME participation rates but the burden of diabetes as well. Understanding these disparities is critical for guiding control programs geared at improving participation rates and diabetes outcomes. Therefore, the objectives of this study were to: (a) investigate geographic disparities of diabetes prevalence and DSME participation rates; and (b) identify predictors of the observed disparities in DSME participation rates. Methods Behavioral Risk Factor Surveillance System (BRFSS) data for 2007 and 2010 were obtained from the Florida Department of Health. Age-adjusted diabetes prevalence and DSME participation rates were computed at the county level and their geographic distributions visualized using choropleth maps. Significant changes in diabetes prevalence and DSME participation rates between 2007 and 2010 were assessed and counties showing significant changes were mapped. Clusters of high diabetes prevalence before and after adjusting for common risk factors and DSME participation rates were identified, using Tango’s flexible spatial scan statistics, and their geographic distribution displayed in maps. Determinants of the geographic distribution of DSME participation rates and predictors of the identified high rate clusters were identified using ordinary least squares and logistic regression models, respectively. Results County level age-adjusted diabetes prevalence varied from 4.7% to 17.8% while DSME participation rates varied from 26.6% to 81.2%. There were significant (p≤0.05) increases in both overall age-adjusted diabetes prevalence and DSME participation rates from 2007 to 2010 with diabetes prevalence increasing from 7.7% in 2007 to 8.6% in 2010 while DSME participation rates increased from 51.4% in 2007 to 55.1% in 2010. Generally, DSME participation rates decreased in rural areas while they increased in urban areas. High prevalence clusters of diabetes (both adjusted and unadjusted) were identified in northern and central Florida, while clusters of high DSME participation rates were identified in central Florida. Rural counties and those with high proportion of Hispanics tended to have low DSME participation rates. Conclusions The findings confirm that geographic disparities in both diabetes prevalence and DSME participation rates exist. Specific attention is required to address these disparities especially in areas that have high diabetes prevalence but low DSME participation rates. Study findings are useful for guiding resource allocation geared at reducing disparities and improving diabetes outcomes.

Geographic disparities in COVID-19 testing and outcomes in Florida

“…The clustering of high COVID-19 hospitalization and mortality risks in Southern Florida may be a reflection of the disproportionate burden of COVID-19 borne by Black and non-white Hispanic/Latino communities [ 75 , 76 ]. These communities are particularly vulnerable to severe illness and death due to higher rates of medical risk factors for COVID-19 morbidity and mortality, such as diabetes mellitus, obesity, hypertension, cardiovascular disease and lung disease [ 77 – 81 ]; high rates of tobacco smoking [ 82 ]; limited access to high quality healthcare [ 34 , 83 , 84 ]; and higher levels of ambient pollution, such as NO 2 and PM 2.5, due to residence in close proximity to sources of air pollution and longer distance from regulatory air quality monitoring compared to white communities [ 85 – 87 ]. This is in spite of substantial reductions (~ 50%) in passenger vehicle traffic in the least white urban communities during the lockdown period [ 87 ].…”

“…The identification of high-risk clusters in Calhoun, Gadsden, and Jackson counties in Northwest Florida both when hospitalized cases were -divided by the total number of cases and by the county population suggests that despite the lower COVID-19 incidence risks in Northwest Florida compared to Southern Florida, a large proportion of the cases in Northwest Florida were severe enough to warrant hospitalization. Northwest Florida is a predominantly rural region with large proportions of black and older residents, and high burdens of comorbidities such as diabetes, hypertension and cardiovascular disease [ 81 , 100 – 102 ]. Moreover, similar to what was reported for black patients in California [ 103 ], limited access to outpatient testing sites in Northwest Florida [ 37 ] may result in a large proportion of black segments of the population accessing testing in hospitals when symptoms are already severe.…”

“…It is worth noting that despite reduced opportunities for the SARS-COV-2 virus to spread in the sparsely populated rural Florida counties, these locales have, on average, larger proportions of older (> 65 years) residents and higher burdens of underlying chronic health conditions such as obesity [ 117 ] diabetes [ 81 , 101 ], hypertension [ 100 ], and heart disease [ 102 , 118 , 119 ] compared to urban counties. Rural areas also tend to have low health insurance rates and a less robust healthcare infrastructure [ 120 – 123 ].…”

Investigating Racial and Ethnic Differences in Diabetes Self-Management Education Among Adults With Diabetes

“…This finding is consistent with previous studies. 9,18,19 It is striking to note the extent that racial and ethnic disparities in DSME participation have persisted over the last decade. Cultural and linguistic barriers have been identified as potential reasons for the low participation rate.…”

“…8,17 That is, being Hispanic or Black is associated with less likelihood of DSME participation compared to being White. 9,18,19 These studies, however, either relied on state-level data or did not make race and ethnicity a central component of their analyses. In contrast, this study focused on the racial and ethnic differences in DSME participation using a population-based, nationally representative large and diverse sample of adults with diabetes to determine whether DSME participation uptake is different among non-Hispanic Whites individuals compared with racially and ethnically minoritized individuals.…”